Sports Injuries – What Would a Doctor Do?

The BJJ Cavewife told me about a discussion she recently had with some of her friends.

In the past few weeks, as the BJJ Cavewife has increased her training volume she’s suffered a few minor injuries. Nothing serious, just a few tweaks here and there which is pretty much par for the course when doing any athletic activity, especially a martial art like Brazilian jiu-jitsu. By the way I know just how lucky I am to be married to someone who also loves to train!

When she told her friends about her injuries, they immediately expressed their concern and told her to see an orthopedic surgeon.

My wife knew that this was complete overkill and tried to explain that her extremely handsome and intelligent husband had advised her that seeing an orthopedic surgeon was completely unnecessary and brought her to a chiropractor instead.

Ok, she may not have used those exact words… but the gist was the same.

Her friends were appalled, and before the BJJ Cavewife could finish her explanation, they interrupted her by saying that chiropractors aren’t REAL doctors because they don’t have to go to medical school and that she should just see an orthopedic surgeon before she gets even more injured.

A little background on the BJJ Cavewife’s extremely handsome and intelligent husband

Now before I go further, I have a confession to make. I’ve never explicitly mentioned this on my blog before, so I’m doing so here: I am a doctor.

My education includes:

4 years of college

4 years of medical school

1 year of internship in internal medicine

4 years of residency specializing in radiology

1 year of fellowship subspecializing in musculoskeletal radiology

During my fellowship, I read studies for professional sports teams in the NHL and MLB and worked with their team surgeons.

As a specialist in musculoskeletal radiology, my job is to work closely with orthopedic surgeons and sports medicine physicians to interpret imaging studies for their patients. I read the full gamut of MRIs, CTs, ultrasounds, X-rays, and nuclear medicine scans in patients of all ages. I also perform steroid and contrast injections into various joints.

I diagnose injuries such as ligament tears, tendon tears, meniscal tears, and fractures on a daily basis and see what they look like after surgery when humpty dumpty is put together again.

Occasionally the surgeries don’t go well and there are complications and I see those too.

I don’t say any of this to brag, but just to give the background that I have formal training in conventional medicine and have an intimate understanding of how the field of medicine works.

Because I’m also a fairly curious fellow, I like to learn about a lot of things that don’t really fall into the purview of conventional MD training, and from time to time experiment with this stuff, as I’m sure readers of this blog know.

A Limited Toolset

Now you may be wondering why I recommended the BJJ Cavewife to see a chiropractor instead of a medical doctor.

Here’s why:

Medical doctors actually have a very limited tool set. In any area of medicine, whether it’s sports medicine, general surgery, oncology, etc. treatment is divided into two main branches: surgical or non-surgical.

If you suffer a major injury like a fracture, complete muscle tear, complete tendon tear (like an Achilles rupture), or complete ligament tear (like an ACL tear) then the first stop should be to an orthopedic surgeon without delay.

If it’s a tendon, muscle or ligament tear, most of the time they’ll get an MRI (which will be read by someone like me) to get a lay of the land before taking you into surgery. If it’s a fracture they’ll get x-rays and maybe a CT-scan (which will also be read by someone like me).

Minor injuries like muscle or tendon strains and ligament sprains are treated non-surgically, which typically involves the standard combination of rest, ice, compression, and elevation (RICE), maybe a brace or splint for immobilization, and NSAIDs for pain control. An x-ray may be ordered which usually won’t show anything except for some swelling. Some doctors may even recommend physical therapy depending on the symptoms.

Whether you walk into a general practitioners office, an emergency department, or an orthopedists office, this is what you can expect.

If you think about it, there really isn’t much to work with. It’s either RICE or surgery.

The trick of course is recognizing what constitutes a major and minor injury which given my clinical background, isn’t hard for me to do. Since it’s too much to get into here, I’ll probably write a separate post on this.

Expanding the Toolset

In the past whenever I’ve gotten hurt, if I wanted to return to activity faster, the typical recommendation I’d receive was to just continue to rest, compress, and elevate until whatever hurts doesn’t hurt anymore (ice is only helpful in the first few days).

As an impatient millennial, this wasn’t enough for me. There HAD to be something else and none of my medical textbooks had the answer.

The Functional Movement Screen is a way to assess movement and isolate asymmetries, restrictions, and/or dysfunctional motor patterns that can lead to injury. This can only be used in the absence of pain.

I see the FMS as a sort of early warning system for a future injury.

The Selective Functional Movement Assessment is a way to determine why a certain area is in pain, when viewed through the lens of the body as a whole.

You may be wondering how this is different from a typical medical exam. In a typical exam you would go to the doctor and say something like, “Doc, my right knee hurts.”

The doctor would then examine your right knee. He may even try some fancy maneuvers like the McMurray’s test or the anterior drawer test, but the focus will almost entirely be on your right knee.

The SFMA however would involve looking at your right knee, then looking at your right ankle and right hip. The practitioner will even feel around all the muscles in your right thigh and calf.

Depending on what they find, they may even look at the hip, knee, and ankle on your left side, and then move upwards to assess your spine and shoulders.

Why? Because they’re all connected.

A restriction in your left shoulder can lead to changes in your spine, which affect the tilt of your pelvis, which can alter your gait, leading to pain in your right knee. Only an approach like the SFMA that views the body in its entirety will uncover this.

Active Release Technique is a special form of soft tissue manipulation that can be used to treat the issues uncovered by the FMS and SFMA. This is more comprehensive than a typical massage, and involves applying pressure to a site while moving the adjacent joints through their ranges of motion to free up soft tissue restrictions.

In my experimentation, I’ve found the combination of FMS, SFMA, and ART to be extremely powerful and effective, so it was important for me to find someone who was certified in all three (you can do a search in your area for certified FMS/SFMA practitioners here and certified ART practitioners here).

While the FMS is meant to be performed by anyone (you can even do it to yourself), the SFMA is performed by a physical therapist, chiropractor, or MD.

ART is typically practiced by chiropractors, although physical therapists and MDs can also learn it.

In our area, there were only 2 practitioners who were trained in all three, and they both happened to be chiropractors, which is how I found the doctor that I’ve been working with to injury proof my body.

Back to the story

When the BJJ Cavewife first told me about her injury, I examined her and immediately recognized it as minor, which is why I didn’t think it was necessary for her to see an orthopedist. They would have just told her to RICE it, which we were doing already.

The muscle she tweaked was in an area that had been nagging her on and off for the past few years. Every once in a while she would do something to irritate it and it would become painful and uncomfortable. Unfortunately this time it was a BJJ technique she was practicing that caused it to act up.

I brought her to the chiropractor I’ve been working with who examined her and performed an SFMA focused on her site of pain. When he was sufficiently satisfied in identifying what the issue was, he proceeded to apply ART to her.

It was painful and he constantly asked her to quantify how bad the pain from his pressure was on a scale of 1-10. He wanted to keep her at a 5 out of 10 to balance her comfort with the efficacy of his treatment.

After about 15 minutes of treatment she was almost pain free! She went from being semi-immobilized by stiffness and pain to 90% of normal. By the end of the second session she was back to 100%.

Despite being completely asymptomatic, the fact that this area kept acting up indicated that there was something else going on, so the next session was spent trying to figure that out.

It turns out that the BJJ Cavewife’s right glutes were extremely weak which made her susceptible to this recurrent injury. Almost a decade ago she suffered a tear of her ACL that was surgically repaired, and it was probably this event that lead to compensations in her movements and muscles that caused the right glutes to become inactive.

Being the inquisitive guy that I am, I wanted some objective proof of this, so the good doctor had her do some exercises which showed just how dramatically asymmetric her glutes were.

While her right side was only slightly smaller than her left, the difference being barely visible, it was about 60% weaker. She could complete 15 clamshells with her left side easily, but could only do 5 or 6 with her right before completely fatiguing.

He did some more ART and prescribed exercises for her to do at home, which we’ve been working on.

Since then the BJJ Cavewife has been completely symptom free and the problem area hasn’t acted up despite her getting back onto the mats for more regular BJJ training.

We plan to get an FMS done on her in her next session to help us figure out what to work on next to make her more resilient to injury.

Parting Thoughts

As an MD and self-experimenter, the message that I want to get across with this post is that there is a lot more out there than RICE and surgery, and you might benefit from exploring some of these options yourself.

I’ve met people, like the BJJ Cavewife’s friends, who believe that all non-MD-doctors are quacks and hucksters and I’m ashamed to admit that I used to believe this too.

The whole MDs-know-best culture was pervasive throughout my training and led me to dismiss a lot of potentially beneficial things early in my career.

Fortunately, the longer I work, the better I understand what MDs are good at and what they aren’t so good at, especially when dealing with sports injuries. I’m now much more open to exploring alternative therapies whether they’re provided by an MD or not, as long as it makes sense to me.

I’m glad the stumbled across the FMS, SFMA, and ART, and I know the now pain-free BJJ Cavewife is too.

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